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Corticosteroids should be applied sparingly to the dermatitis twice daily and rubbed in well Their potency should be appropriate to the severity of the dermatitis In general,
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Akdis CA et al; European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report J Allergy Clin Immunol 2006 Jul;118(1):152 69 [PMID: 16815151] Boguniewicz M et al Atopic dermatitis J Allergy Clin Immunol 2006 Jul;118(1):40 3 [PMID: 16815136] Brown S et al Atopic and non-atopic eczema BMJ 2006 Mar 11;332(7541):584 8 [PMID: 16528081] Williams HC Clinical practice Atopic dermatitis N Engl J Med 2005 Jun 2;352(22):2314 24 [PMID: 15930422]
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response Occasionally, adding tar preparations such as LCD (liquor carbonis detergens) 10% in Aquaphor or 2% crude coal tar may be beneficial 4 Maintenance treatment Once symptoms have improved, constant application of effective moisturizers is recommended to prevent flares In patients with moderate disease, weekend only use of topical corticosteroids can prevent flares
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Systemic corticosteroids are indicated only for severe acute exacerbations Oral prednisone dosages should be high enough to suppress the dermatitis quickly, usually starting with 40 60 mg daily for adults The dosage is then tapered to nil over a period of 2 4 weeks Owing to the chronic nature of atopic dermatitis and the side effects of chronic systemic corticosteroids, long-term use of these agents is not recommended for maintenance therapy Classic antihistamines may relieve severe pruritus Hydroxyzine, diphenhydramine, or doxepin may be useful the dosage increased gradually to avoid drowsiness Fissures, crusts, erosions, or pustules indicate staphylococcal infection clinically Antistaphylococcal antibiotics given systemically such as dicloxacillin or firstgeneration cephalosporins may be helpful in management Cultures to exclude methicillin-resistant S aureus are recommended Phototherapy can be an important adjunct for severely affected patients, and the properly selected patient with recalcitrant disease may benefit greatly from therapy with UVB with or without coal tar or PUVA (psoralen plus ultraviolet A) Oral cyclosporine, mycophenolate mofetil, or azathioprine may be used for the most severe and recalcitrant cases
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LICHEN SIMPLEX CHRONICUS (CIRCUMSCRIBED NEURODERMATITIS)
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Chronic itching and scratching Lichenified lesions with exaggerated skin lines overlying a thickened, well-circumscribed scaly plaque (Plate 3) Predilection for nape of neck, wrists, external surfaces of forearms, lower legs, scrotum, and vulva
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General Considerations
Lichen simplex chronicus represents a self-perpetuating scratch-itch cycle
Clinical Findings
Intermittent itching incites the patient to scratch the lesions Itching may be so intense as to interfere with sleep Dry, leathery, hypertrophic, lichenified plaques appear on the neck, ankles, perineum, or almost anywhere The patches are rectangular, thickened, and hyperpigmented The skin lines are exaggerated
Complications of Treatment
The clinician should monitor for skin atrophy Eczema herpeticum, a generalized herpes simplex infection manifested by monomorphic vesicles, crusts, or erosions superimposed on atopic dermatitis or other extensive eczematous processes, is treated successfully with oral acyclovir, 200 mg five times daily, or intravenous acyclovir in a dose of 10 mg/kg intravenously every 8 hours (500 mg/m2 every 8 hours) Tacrolimus and pimecrolimus increase the risk of eczema herpeticum Smallpox vaccination is absolutely contraindicated in patients with atopic dermatitis or a history thereof because of the risk of eczema vaccinatum Generalized vaccinia may develop in patients with atopic dermatitis who have contact with recent vaccine recipients who still have pustular or crusted vaccination sites Eczema vaccinatum and generalized vaccinia are indications for vaccinia immune globulin
Differential Diagnosis
This disorder can be differentiated from plaque-like lesions such as psoriasis (redder lesions having whiter scales on the elbows, knees, and scalp and nail findings), lichen planus (violaceous, usually smaller polygonal papules), and nummular (coin-shaped) dermatitis Lichen simplex chronicus may complicate chronic atopic dermatitis
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